Strategies for Avoiding Nut Allergies in Schools May Be Overblown

BOSTON -- The threat of nut allergies has led some schools to put precautions into place that approach the level of hysteria, a researcher here said.

Action Points

Explain to interested patients that the author of this commentary concluded that some strategies for avoiding allergic reactions to nuts -- like banishing nuts from school grounds -- may do more harm than good.

BOSTON, Dec. 10 -- The threat of nut allergies has led some schools to put precautions into place that approach the level of hysteria, a researcher here said.

Citing the evacuation and cleaning of a bus full of 10-year-olds because of a single peanut on the floor, Nicholas Christakis, M.D., Ph.D., M.P.H., of Harvard, said that measures such as these amount to mass psychogenic illness -- also known as "epidemic hysteria."

Some schools have not only banned nuts and nut products, but also homemade baked goods and foods without detailed lists of ingredients, he wrote in a commentary published online in BMJ.

Not only is there no evidence that drastic measures like removing nuts from schools are effective or worth the cost, according to Dr. Christakis, exaggerated responses may actually worsen the problem by increasing sensitization to the allergens.

According to Dr. Christakis, the extreme reactions to nut allergies in schools have similarities to mass psychogenic illness, which is characterized by a "cascade of anxiety" in otherwise healthy people prompted by fears of contamination. He suggested, instead, "using a calm and authoritative approach."

The drastic action of banishing nuts and nut products from school grounds can contribute to the problem in two ways -- by increasing sensitivity to nuts and by fueling anxiety among parents, he said.

Anxious parents have their children tested, and when minor nut allergies are detected, more avoidance is encouraged, he said.

He said such responses are excessive considering the minimal risk associated with food allergies. Among the 3.3 million Americans who are allergic to nuts, each year 2,000 children and adults are hospitalized for it and 150 die from all food allergies combined.

By comparison, he noted that each year 45,000 people die in car accidents, 2,000 children drown, and 1,300 children are killed in accidental shootings.

"The cycle of increasing anxiety, draconian measures, and an increasing prevalence of nut allergies must be broken," Dr. Christakis said.

Calman Prussin, M.D., head of the Adverse Reactions to Vaccines and Biologics Unit of the National Institute of Allergy and Infectious Diseases in Bethesda, Md., agreed with Dr. Christakis' point that the way schools deal with risks is not always rational.

"We don't tend to make our risk assessments in a very sensible way, whether it's as individuals or as a society," he told MedPage Today.

There is some evidence to support the contention that strict avoidance can worsen events. A study published in the November issue of the Journal of Allergy and Clinical Immunology found that earlier and more frequent consumption of peanuts or peanut butter may reduce the risk of peanut allergy, contrary to conventional thinking. (See: Early and Frequent Peanut Consumption Linked to Lower Goober Sensitivity)

However, according to Dr. Prussin, the question about whether avoidance or exposure to peanuts increases risk of developing a peanut allergy remains unanswered. "The bottom line is we don't have enough information," he said.

He did not make any specific recommendations, but guidelines issued by the National School Boards Association, the Food Allergy & Anaphylaxis Network, the National Association of Secondary School Principals, the National Association of School Nurses, and the National Association of Elementary School Principals outline steps that parents and schools can take to reduce the risk of serious allergic reactions to foods.

The family's responsibility includes:

Notifying the school about the child's allergies

Developing a plan to accommodate the child's needs, including a food allergy action plan

Providing written medical documentation of the allergy

Providing medications and replenishing them as necessary

Educating the child about recognizing safe and unsafe foods, ways to minimize exposure, and symptoms of allergic reactions

Reviewing procedures with the school staff, the child's physician, and the child after a reaction occurs

The school staff should:

Be aware of and follow applicable laws addressing food allergy

Review health records of allergic students

Include affected children in all school activities

Create a team to work with the child and family in establishing a prevention plan

Ensure that all medications are stored properly

Practice the food allergy action plan before a reaction

Educate all individuals who will come into contact with the child about food allergies

Enforce a "no eating" policy on school buses

In addition, the child should not trade food with others or eat anything with unknown ingredients, should be proactive in managing the allergy, and should notify an adult if anything with unknown ingredients is eaten.

Absent from the guidelines and the practice parameters on managing food allergy from the American Academy of Allergy, Asthma, and Immunology is a recommendation to completely avoid eating nuts.

Despite such a clear plan, however, a study presented at the 2008 AAAAI meeting in Seattle suggested that food allergy action plans may be lacking in many schools.

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